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1 

2 

3 

1 

2 

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6 

f       t  i    >    •     i        4 


L,  ^-..-^  tv  ^  /"r/.  V  /: '.  ..  J  , 


ON  TIIK 


SYSTOLIC  BRAIN   MURMUR 


OF 


OHJLDEEN. 


BY 


AVTLLIAM    ()SI;KR,  1\I.  D.,  INI.  U.  C.  V.  Lond., 

PROFESSOR    01'  TUK    INSTITUTKS    OF    MKDiriM:,    MCCillX    UMVKKSITY,   MONTUEAl, 


[liijiriiitfdfioin  tlw  /Joston  MtiUcal  ainl  Surgical  Journal.] 


CAMBRIDGE : 

^txntcb  at  tt^t  iii\}cmr}t  ptc^0< 

1880. 


rfm 


ON    THE 


» 


SYSTOLIC  BKAIN  MURMUR  OF  CHILDREN. 

BV    Wll.  .1AM    09LKK,    M.    I).,   M.   R.    C.    1'.    LOND., 
Professor  of  tke  Inuituux  of  Medicine,  Med  Hi.  University,  Muntreal. 

I  DKSIKK  in   the  fuilowin^i:  communication   to  call 
attention  to  this  interestiii«,'  clinical  phenomenon,  first 
(lescrihed  hy  Dr.  J.  Fisher,  of  Boston,  in  the  Medical 
Magazine  for  1H3;!.      Like  many  other  observations, 
this  one  has  .-uffered  from  the  lapse  of  time,  and  has 
been,  to  a  great  extent,  forjiotten  and  neglected.     In 
conversation  with  many  physicians,  some  of  them  spe- 
cially conne«-ted  with  pediatrics,  1  have  been  surprisetl 
to  find  how  few  were  even  aware  of  the  existence  of 
such  a  murmur.     Very  cursory  nuiJition  is  made  of  it 
in  works  on  auscultation  and,  with  a  few  exceptions, 
those  on  disi.'ases  of  children.     \]\>  to  1803  the  Ger- 
man and  Freiich  physicians  had  written  many  papers 
on  the  subject,  an<l  within  the  past  few  years  interest 
has  been  re-arous«;d  in  it  by  the  publication  of  impor- 
tant memoirs  byJurasz^  and  Epstein.-     p:nglish  and 
American  physicians  have  not  given  it  much  attention, 
and  in  the  literature  as  collected  by  Jurasz  tlie  only 
references  are  AVhitney,  the  American  Journal  Medical 
Sciences,  1643,  and  d.  W.  Smith,  the  Lancet,  18o9. 

In  the  autumn  of  187G.  1  was  asked  by  a  medical 
friend  to  see  a  child,  aged  three  years,  with  a  remark- 
able  murmur   in   the   head,  about  which   the   parents 

1  I)a»  3VstoIiscl«e  HiniKPriiuscli  tier  Kinder,     IleidelberK-   1877. 
'-  Heitra'f:  zur  K.niitniss  iles  sysU.lischcn  Schadelgertiusches  der 
Kinder.    Trag.    1S78. 


4      The  Systolic  Brain  Murmur  of  Children. 


were  very  anxious.  Tlie  cliild  was  a  wt'll-noiirislicid 
little  girl,  with  a  ruddy  complexion,  well-lbrn)ed  head, 
I'ontanelles  closed  ;  no  evidences  of  rickets.  On  |»1mc- 
ing  the  ear  upon  any  part  of  the  head  a  loud,  high- 
pitched  systolic  inunnur  could  be  heard,  variable  in 
intensity,  loudest  in  the  temporal  regions,  also  audible 
in  the  carotids,  and  disappearing  entirely  on  compres- 
sion of  these  vessels.  There  was  no  heart  disease. 
The  mother  had  noticed  the  noise  in  the  head,  she 
thought,  from  the  time  the  child  was  a  year  old,  and 
the  child  also  appeared  conscious  of  its  j)rescncc,  but 
s:«id  she  only  heard  it  at  intervals.  The  medical  at- 
tendant had  suijirested  the  jiossibilitv  of  aneurisu),  but 
there  did  not  seem  to  me  to  be  nny  evidence  in  favor 
of  such  a  view.  I  had  a  distinct  recolI(M'tion  of  the 
fiict  that  :i  murmur  was  described  as  occurring  in  the 
brains  of  children,  but  1  thought  it  was  always  audible 
over  an  opi'U  fontanelle,  Jind  ]);ii'taking  of  the  nature 
of  a  venous  hunn  oriuinatinjx  in  the  lonjifituditial  sinus. 
As  the  child  was  in  jjood  health,  and  the  murmur 
hiul  persisted  for  nearly  two  years,  I  gave  a  favorable 
prognosis.  The  mother  did  not  aj)iiear  satislied,  but 
I  heard  nothing  fv-i  ther  of  the  case  for  some  months, 
when  1  recogu'/ed  ii  in  the  description  of  a  Case  of 
Supposed  (iununy  Tumor  of  the  lirain,  in  which  the 
murmur  was  ."itributed  to  the  possible  existence  of  a 
svphilitic  growth  pres.-ing  uj)on  the  vessels  at  the  base 
of  the  brain.  About  the  same  time  Juras//s  memoir 
came  to  hand,  and  renewed  my  interest  in  tlu^  case, 
which  lijis  proved  to  be  one  of  unusual  value  froni  the 
length  of  time  whicn  the  nmrmur  has  continued.  The 
history  of  the  child  from  the  spring  of  1877  to  the 
ju'esent  is  as  follows:  she  has  thriven,  and  is  now  a 
l)right,  intelligent  little  girl  of  seven,  ])erfectly  healthy, 
luvid  not  enlarged,  and  no  trace  of  swollen  lymphatic 
glands  in  the  neck.  1  have  examined  her  on  four  oc- 
casions, and  found  the  murmur  peisistent,  with  the 
same  characteristics.     On  the  15th  of  May  of  the  pres- 

year  1  examined  her  again,  and  found  it  still  very 
ent 


V 


The  Syatollc  Brain  Murmur  of  tViilihrn.      5 


J<: 


(]istiuot,  loudest  in  tli(!  teinpoiMl  r«'Lji<)!is.  r.itlici'  ukm'o 
vjirial)lo  in  iiitciisitv  tlum  liifluTto,  uinl  .soiiu'tiiiuvs  dis- 
appcuriiiij  ontirely  for  a  feu  moments.  It  was  with 
dilliciilty  lu;anl  in  tlio  carotids. 

I  have  examined  ahont  sixty  <'hildren  for  this  mur- 
mnr,  and  have  discovered  it  in  ei;^ht  cases,  all  nn- 
der  tliree  vears  of  a;;e :  t)iie,  a  case;  of  dironie  hydro- 
cephiiins;  one,  chronic  intestinal  car.'iri'h  with  rick«'ts  ; 
tlie  others  appeared  In.'althy.  Anion;:  the  sick  chil- 
dren examined  in  whom  no  mnrmnr  existed  were  s«^v- 
eral  cases  of  rickets,  two  of  tuhercnlons  meninuitis,  and 
one  of  chronic  hydr()ceph:dns.  Dr.  .lames  IJell,  lat*) 
honse  snrn;e()n  of  the  ^Slontical  (Jeneral  Hospital,  ex- 
amined one  hundred  eliildrcM,  and  found  only  six  in- 
stances of  the  "brain  nmrnuir;"  hnt,  as  he  remarked, 
th(!  dillienlty  of  (letectinij  a  soft,  lo.v-pitched  /irin'f  in 
tin;  head  of  a  strnL'.ulin.U  ejiild  in  a  busy,  "  ont-door  " 
room  makes  it  prol)al)le  that  in  many  instan(n's  it  was 
overlooked.  No  special  iH)te  was  ke[)t  in  these  cases 
of  the  condition  of  tlu!  children. 

( )l»,s(!rvers  differ  very  nmcli  in  their  estimation  of  tho 
import  of  this  nun-nmr,  some  re^ardini;-  it  as  patlmloj;- 
ica!.  otliei-s  as  physiological.  Dr.  Fisher  lhon<fht  it  to' 
he  I  he  former,  and  described  variations  of  the  nuninni' 
in  such  disi^ases  as  wlioo|tiii^'  (ion^li.  conu'estion  of  the 
brain,  acute  and  chronic  hvdrocc[)lialus,  and  apo|>lexy. 
liarthez  and  Killiet  (IS."»;1)  thcujiht  that  it  afforded 
a  di;iiinostic  si,i;n  between  racliiiic  hypertrophy  of  tho 
brain  and  chronic  hydrocephalus.  IJoi^er  (l.sr)*.))  and 
Henoch  (1>S()1)  regarded  it  as  specially  connected  with 
rickets.  Wirthiicn  ( IS.';,")),  on  ^he  other  luuid,  lielieved 
it  to  be  jdiysiolo^ical.  and  stati's  that  it  is  heard  nn>st 
frc(!uentlv  oMsr  the  heads  of  robust  children.  The 
views  ot  these  and  other  writers  are  i;ivcn  very  fully 
in  «Iuras//s  mono^i'aph,  and  the  di^C()rdance  of  opinion 
is  amply  illustrated..  This  author  coii(;lndes  that  it  is 
not  ])atholouical,  but  occurs  in  both  healthy  ami  dis- 
eased  children,  and  does  not  stand  in  direct  connection 
with  any  {)articular  disease.     In  reading  over  the  rec- 


G       The  Systolic  Brain  Murmur  of  Children. 

onls  of  cases   it  is  ccirtaiiily  noteworthy  liow  freiiuent 
tlio  suhjcct  of  tii(!  murrnur  is  described  as  rickety. 

Tlieri!  iM  remarkiihlo  iiiiaiiimity  ainoiiir  all  tlu^  writers 
as  to  the  ai,'o  at  which  the  iniirinur  i)n'vail.s,  the  ex- 
tremes in  the  reconled  cases  heiiijr  l)ie  third  month  and 
the  sixth  year,  the  majority  of  instances  occurring  dur- 
ing the  second  year.  The  cas(!  of  the  litth'  girl  above 
given  is  of  interest,  therefore^,  in  this  connection,  as  she 
is  now  over  seven  years  of  a^'e,  and  further  from  the 
fact  of  th(}  persistence  of  the  murmur  since  infancy.  I 
have  not  found  any  recorded  instance  of  the  murmur 
persisting  for  such  a  length  of  time. 

Tlu!  seat  of  the  prochiction  of  the  niurmur  is  placed 
by  most  authors  in  the  arteries  at  the  base  ol  llu5  brain 
and  in  llu^  carotid  <'anal.  Ilennig  believed  it  to  be 
venous,  and  jiroduced  in  the  longitudinal  sinus.  It  is 
worthy  of  note  that  in  the  majority  of  the  cast's  a  mur- 
mur  is  also  heard  in  the  carotid  arteries. 

tJurasz  has  brought  forward  evidcfiict!  to  prove  that  tlio 
murmur  originates  in  the  carotid  canul,  and  as  his  ex- 
planation of  it  has  not.  sofai'as  I  know,  been  j)ublished 
in  any  Iviglish  oi-  American  Jmirnal,  it  may  be  worth 
whil(!  to  give  a  smnmary  of  his  views  :  lie  measured 
the  width  of  the  upper  and  lower  orilices  of  the  carotid 
canal  in  twenty-live  adults  and  tw(!nty-liv(?  new-born 
infants.  Jn  the  former  the  inferior  aperture  varied 
from  (i.l  m.  to  1  cm.  in  ti:  ;  long,  and  0.4  to  7.(1  m.  in 
the  short  dianu'ter;  the  superior  aperture  from  T).  I 
to  8  m.  in  the  longest,  and  .">..')  to  7. 1  m.  in  the  shortest 
diameter.  JMeasuiements  in  the  mature  lu'tus  and  new- 
born when  compart.'d  with  these  show  a  diilerenc(!  of 
from  4.1  to  G.2  m.  for  the  long,  and  .1.7  to  4.0  ni.  for 
the  short  diameter  of  the  inferior  aperture,  and  o.I  to 
4..')  m.  for  the  loui;,  and  o.o  to  o.l)  m.  for  the  short  di- 
ametcM'  of  tin;  superior  aperture.  The  carotid  canal 
must  therefore  enlarge  considerably  in  the  course  of 
development.  Does  this  take  place  gradually,  or 
<loes  it  occur  more  rapidly  at  one  [)eriod  than  another? 
His  observations  ami  measurements  go  to  show  that  up 


Tlie  Systolic  Brain  Murmur  of  Children.      7 

to  the  sixth  month  the  caiial  dot's  not  enhir^e,  remain- 
ing UMcliun^od  ;  hut  from  this  (hito  it  widens  rapidly,  so 
that  from  iha  third  to  the  sixth  year  the  (limensions  of 
the  adult  canal  are  attained.  The  enlargement  is  held 
to  he  due  to  the  increase  in  volumi!  of  the  carotid  artery, 
and  not  to  an  independent  growth,  that  is,  expansion, 
of  the  hone;  and  this  heing  the  case  it  is  not  impossihle 
that  a  temporary  local  disproportion  ensues  hetwetni 
the  rapidly  enlarging  caroti'l  artery  and  the  surround- 
ing hony  wall,  or,  •'  in  other  words,  a  temporary  steno- 
sis of  the  carotid  takes  plac(;  in  the  carotid  cnnal." 
This  physiological  stenosis  is  held  to  he  the  cause  of 
the  systolic  hrain  murmur,  which  is  to  he  regarded  as 
a  normal  occurrence.     It  is  the  expression  of  a  struircle 

1  1  1     •  I  •  OO 

hetween  the  artery  and  its  hony  nivestment,  which  per- 
sists until  hy  the  pressure  of  the  pulsations  the  canal 
has  heen  widened  to  a  suitahle  deirree. 

Epstein  ^  criticises  this  theory  and  the  anatomical 
data  on  which  it  is  hased,  denying  the  rapid  expansion 
of  the  carotid  canal  aftcu*  the  sixth  nujuth  and  its  en- 
largement hy  the  pulsation  of  the  artery.  Taking  the 
following  circumstances  as  favoring  the  production  of 
vascular  murmurs,  namely,  wide  vessels,  rapid  hlood 
flow,  diminished  peri[)heral  resistance,  elasticity,  and 
thinness  of  the  walls,  he  proceeds  to  show  that  these 
prevail  to  an  unusual  degree  in  infancy,  particularly  in 
tire  vessels  of  the  head,  which,  according  to  IJeneke,  are 
relatively  larger  than  the  others  of  the  hody.  In  children, 
also,  the  arterial  walls  are  thinner,  the  capillaries  wider, 
the  hlood  flow  more  rapi<l,  and  consequently  the  blood 
pressure  is  low.  The  existence  of  such  conditions,  es- 
pecially in  anaemic  children,  is  regarded  as  the  predis- 
posing, if  not  the  exciting,  cause  of  the  hrain  murmur, 
lie  calls  attention  to  a  fact  of  great  im[)ortance  in  this 
connection  :  in  two  cases  there  were  found, /?os<  mortem^ 
enlarged  and  hard  lymph  glands  in  the  course  of  the 
carotid  arteries,  and  in  all  children  examined  subsequent- 
ly^ in  whom  the  murmur  was  heard,  the  presence  of  eu- 

1  Loc.  cit. 


8      Tfie  Systolin  Brain  Murmur  of  Children. 

l{im'<l  irlands  in  tliis  sltiitition  was  (hsU'riiilncd.  Ho 
su<;m'st8  tliat  l\u'.  murmur  may  hv  duci  to  till;  cause. 

So  far  as  my  liinitc<l  exi-tirifiice  goos,  I  am  not  in- 
cliiiod  to  y'ijard  the  murmur  as  of  any  special  patho- 
lo^'ical  si^niilicaMce.  There  can  be  no  (h)uht,  ho\v(!ver, 
Ironi  the  numerous  observations  ol  Krem'h  and(i<'r- 
man  physicians,  that  itoc(Mirs  most  frc-qucntly  in  weak, 
rickety  <;liildr<'ii,  but  its  presence  and  persistence  in  per- 
fectly healthy  infants  are  .sullicient  to  disprove  the  pe- 
culiar connection  which  some  have  sujiposed  it  to  have 
with  this  disease.  Thus  I  havi;  had  a  strong,  wcU- 
devdoped  child  under  observation  since  birth  ;  the  mur- 
mur appeared  at  the  fourth  month,  and  has  now  con- 
tinued for  twenty-two  months,  with  little  or  no  change;. 
Though  not  prepared  to  criticise  Jurasz's  ingenious 
viev/,  not  having  entered  into  the  anatomical  (pu'Stiou, 
1  think  that  the  case's  of  the  little  girl  above  mentioned, 
in  whom  the  murnuir  has  lasted  for  six  years,  and  the 
intant  in  which  1  have  followcil  it  for  twenty-two 
months,  are  strongly  opposed,  if  not  fatal,  to  any  such 
theory.  If  the  carotid  canal  is  wi<lened  b}'  the  [»ulsa- 
tion  of  the  artery,  it  is  scarcely  conceivable  that  a 
2)hysiolo(jical  stenosis  could  j)ersist  for  six  years. 

1  have  not  been  able  Jo  detect  any  special  eidarge- 
ment  in  the  cervical  glaiids  along  the  carotids  in  tlie 
cases  which  have  come  under  observation  since  receiving 
Epstein's  pami)hlet.  In  .)ne  case  there  were  two  en- 
larged and  linn  glands  behind  the  sterno-mastoid  mus- 
cle on  the  right  side.  Unless  the  enlarijement  is  con- 
sidcrable,  it  is  dillicult  to  feel  the  deep  glands  along  the 
carotids,  particularly  if  the  child  is  well  nourished. 
Epstein's  suggestion  is,  however,  worthy  of  further  in- 
vestigation. 


>msiis^^!^0^. 


